Impact on process of trauma care delivery 1 year after the introduction of a trauma program in a provincial trauma center

A quality-improvement approach to effective trauma team activation

Background

Appropriate, timely trauma team activation (TTA) can directly affect outcomes for patients with trauma. A review of quality-performance indicators at our Canadian level 1 trauma centre showed a high level of undertriage, with TTA compliance rates less than 60% for major trauma. A quality-improvement project was undertaken, targeting a sustained goal of at least 90% TTA compliance based on Accreditation Canada guidelines.

Methods

Quality-improvement action followed a well-defined process. Baseline data collection was performed, and, in keeping with the Donabedian approach, we brought together stakeholders to collectively review and understand the reasons behind poor TTA compliance; and root-cause analysis. This was followed by rapid change cycles that focused on structure and processes with ongoing audits to support and sustain change.

Results

Trauma team activation compliance improved from 58.8% to more than 90% over 2 years. Quality indicators showed a statistically significant reduction in the time to computed tomography scanner, time in the acute care region of the emergency department and total time in the emergency department, with improved TTA compliance.

Conclusion

Compliance with TTA protocols improved to more than 90% over a 2-year period, which shows the benefit of having a clearly outlined qualityimprovement process. This well-defined quality-improvement method provides a framework for use by other institutions that seek to improve their processes of trauma care, including activation rates.

Models of care for traumatically injured patients at trauma centres in British Columbia: variability and sustainability

BACKGROUND

Successful trauma systems employ a network of variably-resourced hospitals, staffed by experienced providers, to deliver optimal care for injured patients. The "model of care"-the manner by which inpatients are admitted and overseen, is an important determinant of patient outcomes.

OBJECTIVES

To describe the models of inpatient trauma care at British Columbia's (BC's) ten adult trauma centres, their sustainability, and their compatibility with accreditation guidelines.

METHODS

Questionnaires were distributed to the trauma medical directors at BC's ten Level I-III adult trauma centres. Follow-up semi-structured interviews clarified responses.

RESULTS

Three different models of inpatient trauma care exist within BC. The "admitting trauma service" was a multidisciplinary team providing exclusive care for injured patients. The "on-call consultant" assisted with Emergency Department (ED) resuscitation before transferring patients to a non-trauma admitting service. The single "short-stay trauma unit" employed on-call consultants who also oversaw a 48-hour short-stay ward. Both level I trauma centres utilized the admitting trauma service model (2/2). All Level II sites employed an on-call consultant model (3/3), deviating from Level II trauma centre accreditation standards. Level III sites employed all three models in similar proportions. None of the on-call consultant sites believed their current care model was sustainable. Inadequate compensation, insufficient resources, and difficulty recruiting physicians were cited barriers to sustainability and accreditation compliance.

CONCLUSIONS

Three distinct models of care are distributed inconsistently across BC's Level I-III trauma hospitals. Greater use of admitting trauma service and short-stay trauma unit models may improve the sustainability and accreditation compliance of our trauma system.

Development of a multi stakeholder partnership to improve access to and delivery of neurosurgical services in Ontario

Neurosurgical emergencies require expedient access to definitive care at neurosurgical centers. Neurosurgical resources in province of Ontario are highly centralized, and subsequently, most patients with neurosurgical emergencies will present to non-neurosurgical centers. From 2000-2010, metrics demonstrated the organization of neurosurgical resources might not be optimal. In response to this a program entitled Provincial Neurosurgery Ontario (PNO)- was formed to address these issues in cooperation with neurosurgeons, hospitals and the provincial government. PNO worked with multiple stakeholders to implement interventions to not only prevent out of country transfer, but to also improve the flow of neurosurgical patients in the province and potentially improve outcome. The main interventions undertaken by PNO were: 1) implementation and development of a province-wide tele-radiology system; 2) development of neurosurgery as a provincially-funded program; 3) significant outreach to non-neurosurgical centers; and 4) specialized funding packages for highly specialized level care. This report provides background on the challenges faced by neurosurgery in the province of Ontario and the process developed to address these challenges. Finally, we describe the impact provincial strategies have had on improving access to emergency neurosurgical care in the Ontario.

Incremental cost-effectiveness of trauma service improvements for road trauma casualties: experience of an Australian major trauma centre

Objective The aim of the present study was to estimate the cost-effectiveness of trauma service funding enhancements at an inner city major trauma centre. Methods The present study was a cost-effectiveness analysis using retrospective trauma registry data of all major trauma patients (injury severity score >15) presenting after road trauma between 2001 and 2012. The primary outcome was cost per life year gained associated with the intervention period (2007-12) compared with the pre-intervention period (2001-06). Incremental costs were represented by all trauma-related funding enhancements undertaken between 2007 and 2010. Risk adjustment for years of life lost was conducted using zero-inflated negative binomial regression modelling. All costs were expressed in 2012 Australian dollar values. Results In all, 876 patients were identified during the study period. The incremental cost of trauma enhancements between 2007 and 2012 totalled $7.91million, of which $2.86million (36%) was attributable to road trauma patients. After adjustment for important covariates, the odds of in-hospital mortality reduced by around half (adjusted odds ratio (OR) 0.48; 95% confidence interval (CI) 0.27, 0.82; P=0.01). The incremental cost-effectiveness ratio was A$7600 per life year gained (95% CI A$5524, $19333). Conclusion Trauma service funding enhancements that enabled a quality improvement program at a single major trauma centre were found to be cost-effective based on current international and Australian standards. What is known about this topic? Trauma quality improvement programs have been implemented across most designated trauma hospitals in an effort to improve hospital care processes and outcomes for injured patients. These involve a combination of education and training, the use of audit and key performance indicators. What does this paper add? A trauma quality improvement program initiated at an Australian Major Trauma Centre was found to be cost-effective over 12 years with respect to years of life saved in road trauma patients. What are the implications for practitioners? The results suggest that adequate resourcing of trauma centres to enable quality improvement programs may be a cost-effective measure to reduce in-hospital mortality following road trauma.

Implementation and Evaluation of a Wiki Involving Multiple Stakeholders Including Patients in the Promotion of Best Practices in Trauma Care: The WikiTrauma Interrupted Time Series Protocol

Background

Trauma is the most common cause of mortality among people between the ages of 1 and 45 years, costing Canadians 19.8 billion dollars a year (2004 data), yet half of all patients with major traumatic injuries do not receive evidence-based care, and significant regional variation in the quality of care across Canada exists. Accordingly, our goal is to lead a research project in which stakeholders themselves will adapt evidence-based trauma care knowledge tools to their own varied institutional contexts and cultures. We will do this by developing and assessing the combined impact of WikiTrauma, a free collaborative database of clinical decision support tools, and Wiki101, a training course teaching participants how to use WikiTrauma. WikiTrauma has the potential to ensure that all stakeholders (eg, patients, clinicians, and decision makers) can all contribute to, and benefit from, evidence-based clinical knowledge about trauma care that is tailored to their own needs and clinical setting.

Objective

Our main objective will be to study the combined effect of WikiTrauma and Wiki101 on the quality of care in four trauma centers in Quebec.

Methods

First, we will pilot-test the wiki with potential users to create a version ready to test in practice. A rapid, iterative prototyping process with 15 health professionals from nonparticipating centers will allow us to identify and resolve usability issues prior to finalizing the definitive version for the interrupted time series. Second, we will conduct an interrupted time series to measure the impact of our combined intervention on the quality of care in four trauma centers that will be selected—one level I, one level II, and two level III centers. Participants will be health care professionals working in the selected trauma centers. Also, five patient representatives will be recruited to participate in the creation of knowledge tools destined for their use (eg, handouts). All participants will be invited to complete the Wiki101 training and then use, and contribute to, WikiTrauma for 12 months. The primary outcome will be the change over time of a validated, composite, performance indicator score based on 15 process performance indicators found in the Quebec Trauma Registry.

Results

This project was funded in November 2014 by the Canadian Medical Protective Association. We expect to start this trial in early 2015 and preliminary results should be available in June 2016. Two trauma centers have already agreed to participate and two more will be recruited in the next months.

Conclusions

We expect that this study will add important and unique evidence about the effectiveness, safety, and cost savings of using collaborative platforms to adapt knowledge implementation tools across jurisdictions.

Compliance to advanced trauma life support protocols in adult trauma patients in the acute setting

INTRODUCTION

Advanced Trauma Life Support (ATLS) protocols provide a common approach for trauma resuscitations. This was a quality review assessing compliance with ATLS protocols at a Level I trauma center; specifically whether the presence or absence of a trauma team leader (TTL) influenced adherence.

METHODS

This retrospective study was conducted on adult major trauma patients with acute injuries over a one-year period in a Level I Canadian trauma center. Data were collected from the Alberta Trauma Registry, and adherence to ATLS protocols was determined by chart review.

RESULTS

The study identified 508 patients with a mean Injury Severity Score of 24.5 (SD 10.7), mean age 39.7 (SD 17.6), 73.8% were male and 91.9% were involved in blunt trauma. The overall compliance rate was 81.8% for primary survey and 75% for secondary survey. The TTL group compared to non-TTL group was more likely to complete the primary survey (90.9% vs. 81.8%, p = 0.003), and the secondary survey (100% vs. 75%, p = 0.004). The TTL group was more likely than the non-TTL group to complete the following tasks: insertion of two large bore IVs (68.2% vs. 57.7%, p = 0.014), digital rectal exam (64.6% vs. 54.7%, p = 0.023), and head to toe exam (77% vs. 67.1%, p = 0.013). Mean times from emergency department arrival to diagnostic imaging were also significantly shorter in the TTL group compared to the non-TTL group, including times to pelvis xray (mean 68min vs. 107min, p = 0.007), CT chest (mean 133min vs. 172min, p = 0.005), and CT abdomen and pelvis (mean 136min vs. 173min, p = 0.013). Readmission rates were not significantly different between the TTL and non-TTL groups (3.5% vs. 4.5%, p = 0.642).

CONCLUSIONS

While many studies have demonstrated the effectiveness of trauma systems on outcomes, few have explored the direct influence of the TTL on ATLS compliance. This study demonstrated that TTL involvement during resuscitations was associated with improved adherence to ATLS protocols, and increased efficiency (compared to non TTL involvement) to diagnostic imaging. Findings from this study will guide future quality improvement and education for early trauma management.

Physiotherapy Models of Service Delivery, Staffing, and Caseloads: A Profile of Level I Trauma Centres across Canada

PURPOSE

To examine and describe physiotherapy models of service delivery, staffing, and caseloads in Level I trauma centres across Canada.

METHODS

A telephone questionnaire was administered to one experienced trauma physiotherapist at each of the 19 Level I trauma centres in Canada. Quantitative data were analyzed descriptively for national trends.

RESULTS

Data were collected from all 19 centres (100%), 89% of which provided physiotherapy services 5 days per week with priority weekend coverage. Physiotherapist assistants (PTAs) were employed by 89% of centres and were used across the continuum of care. Centres with PTAs appear to be more likely to provide patients with additional daily treatment. Departmental organizational structures were the most common (41%) and were associated with higher caseloads. Higher caseloads also appear to be linked with having less than 10 years of experience as a physiotherapist.

CONCLUSIONS

Variations exist between centres with respect to the delivery of physiotherapy services. These variations may result from differences in province-specific legislation, differences in funding structure, and the lack of evidence-informed guidelines. Future research is needed to establish optimal models of physiotherapy services that are cost-effective and provide best patient care.

Does direct transport to provincial burn centres improve outcomes? A spatial epidemiology of severe burn injury in British Columbia, 2001-2006

BACKGROUND

In Canada and the United States, research has shown that injured patients initially treated at smaller emergency departments before transfer to larger regional facilities are more likely to require longer stays in hospital or suffer greater mortality. It remains unknown whether transport status is an independent predictor of adverse health events among persons requiring care from provincial burn centres.

METHODS

We obtained case records from the British Columbia Trauma Registry for adult patients (age ≥ 18 yr) referred or transported directly to the Vancouver General Hospital and Royal Jubilee Hospital burn centres between Jan. 1, 2001, and Mar. 31, 2006. Prehospital and in-transit deaths and deaths in other facilities were identified using the provincial Coroner Service database. Place of injury was identified through data linkage with census records. We performed bivariate analysis for continuous and discrete variables. Relative risk (RR) of prehospital and in-hospital mortality and hospital stay by transport status were analyzed using a Poisson regression model.

RESULTS

After controlling for patient and injury characteristics, indirect referral did not influence RR of in-facility death (RR 1.32, 95% confidence interval [CI] 0.54- 3.22) or hospital stay (RR 0.96, 95% CI 0.65-1.42). Rural populations experienced an increased risk of total mortality (RR 1.22, 95% CI 1.00-1.48).

CONCLUSION

Transfer status is not a significant indicator of RR of death or hospital stay among patients who received care at primary care facilities before transport to regional burn centres. However, significant differences in prehospital mortality show that improvements in rural mortality can still be made.

The top five research priorities in physician-provided pre-hospital critical care: a consensus report from a European research collaboration

Background

Physician-manned emergency medical teams supplement other emergency medical services in some countries. These teams are often selectively deployed to patients who are considered likely to require critical care treatment in the pre-hospital phase. The evidence base for guidelines for pre-hospital triage and immediate medical care is often poor. We used a recognised consensus methodology to define key priority areas for research within the subfield of physician-provided pre-hospital critical care.

Methods

A European expert panel participated in a consensus process based upon a four-stage modified nominal group technique that included a consensus meeting.

Results

The expert panel concluded that the five most important areas for further research in the field of physician-based pre-hospital critical care were the following: Appropriate staffing and training in pre-hospital critical care and the effect on outcomes, advanced airway management in pre-hospital care, definition of time windows for key critical interventions which are indicated in the pre-hospital phase of care, the role of pre-hospital ultrasound and dispatch criteria for pre-hospital critical care services.

Conclusion

A modified nominal group technique was successfully used by a European expert group to reach consensus on the most important research priorities in physician-provided pre-hospital critical care.

A review of major trauma admissions to a tertiary adult referral hospital over a ten year period: fewer patients, similar survival

BACKGROUND

Trauma is an important cause for presentation to the emergency department, representing a significant number of emergency surgical admissions. Societal changes result in alterations in the epidemiology of trauma.

OBJECTIVES

This study aimed to review patients admitted to a tertiary referral hospital as a result of traumatic injuries, assessing for changes in admission epidemiology.

METHODS

Trauma admissions over two year-long periods a decade apart were reviewed. The Trauma Audit and Research Network (TARN) audit system identified admissions and transfers between June 2006 and May 2007. The Hospital In-Patient Enquiry (HIPE) system identified those fulfilling TARN criteria a decade earlier. Comparative analysis was performed on the dataset.

RESULTS

There were 367 trauma admissions between June 2006 and May 2007: 88 road traffic accidents (RTAs), 201 falls and 77 other injuries, with 627 admissions a decade earlier: 286 RTAs, 247 falls and 94 others. Males comprised 72% and 69% of RTA admissions in both periods respectively. Firearm-related injuries increased significantly (p = 0.015). Neurosurgical transfers decreased from 256 to 150 with a slight increase in unadjusted overall mortality from 8.5% to 10.9%. Admissions of patients aged less than 19 reduced from 150 to 59 (p = 0.0031) with a similar trend in those aged between 20 and 29 years from 149 to 78.

CONCLUSION

Admissions resulting from RTAs and of patients aged under 30 reduced significantly, however, young males remain the most affected sub-group. Firearm injuries increased significantly, a worrying trend in view of the severity of injury sustained by these victims.

Trauma systems: Do trauma teams make a difference?

This review describes the various components of a trauma team, and emphasises its value as one of many parts of a trauma system. The evidence for the team is weak and based on expert opinion and experience. Nevertheless, the evidence that high quality trauma systems improve survival, and that a trauma team is a vital component of all such systems is compelling. There is no evidence that a particular component of the team is essential. The trauma team is likely to have most impact on patients with moderate severity of trauma and probability of survival.

Long-lasting performance improvement after formalization of a dedicated trauma service

BACKGROUND

Few studies have evaluated intrainstitutional improvement of trauma care. We hypothesized that the formalization of a dedicated multidisciplinary trauma service in a major Scandinavian trauma center in 2005 would result in improved outcome.

METHODS

Institutional trauma registry data for 7,243 consecutive patients from the years 2002-2008 were retrospectively evaluated using variable life-adjusted display (VLAD) as one of several performance indicators. VLAD is a refinement of the cumulative sum method that adjusts death and survival by each patient's risk status (probability of survival) and provides a graphical display of performance over time. Probability of survival was calculated according to Trauma and Injury Severity Score (TRISS) methodology with National Trauma Data Bank 2005 coefficients.

RESULTS

VLAD demonstrated a sharp increase in cumulative survival starting at the beginning of 2005 and continuing linearly throughout the study period, amounting to 68 additional saved lives. The increase was mainly caused by improved survival among the critically injured (injury severity score 25-75). A cutoff point t0 for analysis of differences between time periods was set at January 1, 2005, coinciding with the formalization of a dedicated trauma service. Mortality in the whole trauma population showed a 33% decrease after t0. W-statistics confirmed the increased survival to be significant. There were no significant changes in age, gender, or injury mechanism. Injury severity score decreased, but differences in case mix were adjusted for in the survival prediction model.

CONCLUSION

We have shown that the start of the long-lasting performance improvement coincided with formalization of a dedicated trauma service, providing increased multidisciplinary focus on all aspects of trauma care.

Establishing the evidence base for trauma quality improvement: a collaborative WHO-IATSIC review

BACKGROUND

Quality improvement (QI) programs are an integral part of well-developed trauma systems. However, they have not been extensively implemented globally. To promote greater use of effective QI programs, the World Health Organization (WHO) and the International Association for Trauma Surgery and Intensive Care (IATSIC) have been collaboratively developing the upcoming Guidelines for Trauma Quality Improvement Programmes. As part of the development of this publication and to satisfy global demands for WHO guidelines to be evidence based, we conducted a thorough literature search on the effectiveness of trauma QI programs.

METHODS

The review was based on a PubMed search of all articles reporting an outcome from a trauma QI program.

RESULTS

Thirty-six articles were identified that reported results of evaluations of a trauma QI program or in which the trauma QI program was integrally related to identification and correction of specific problems. Thirteen of these articles reported on mortality as their main outcome; 12 reported on changes in morbidity (infection rates, complications), patient satisfaction, costs, or other outcomes of tangible patient benefit; and 11 reported on changes in process of care. Thirty articles addressed hospital-based care; four system-wide care; and two prehospital care. Thirty-four articles reported an improvement in the outcome assessed; two reported no change; and none reported worsening of the outcome. Five articles also reported cost savings.

CONCLUSIONS

Trauma QI programs are consistently shown to improve the process of care, decrease mortality, and decrease costs. Further efforts to promote trauma QI globally are warranted. These findings support the further development and promulgation of the WHO-IATSIC Guidelines for Trauma QI Programmes.

Improved trauma patient outcomes after implementation of a dedicated trauma admitting service

BACKGROUND

Regionalised trauma systems have been shown to improve the outcome of seriously injured patients. However, it is not clear which components of these systems have the most impact on patient outcomes. The study evaluates the association between implementation of a single, dedicated trauma admitting service at an urban trauma centre and subsequent patient outcomes.

METHODS

This was a retrospective review of prospectively collected trauma registry data at the St George Public Hospital, a level I urban trauma centre in Sydney, Australia. Two concurrent 18-month periods, before and after implementation of a full-time trauma service, were compared for differences in patient mortality, complication rates, and ED, ICU and hospital lengths of stay.

RESULTS

There were 962 patients admitted to the hospital in the 18 months immediately preceding the implementation of the trauma service (the PRE group) and 990 patients in the subsequent 18 months (the POST group). There were no significant differences between groups with respect to patient demographics or mechanism of injury, although a higher proportion of patients in the POST group had injury severity scores (ISS) above 15 (30.6% versus 24.8%, p=0.02). There was an 8% reduction in death rate among the most severely injured patients (ISS>15), in the POST group as compared to the PRE group (12.2% and 20.2% respectively, p=0.007).

CONCLUSIONS

The implementation of a full-time trauma service in this hospital was associated with a reduction in death rate among the most severely injured patients, and a decrease in LOS in patients with an ISS<15.

Model for the reconfiguration of specialized vascular services

Background

This article built on previous work to develop an algorithm for elective abdominal aortic aneurysm (AAA) repair and carotid endarterectomy (CEA), with the aim of improving patient survival by regionalization of services. Vascular procedures were used as an example of specialized surgical services.

Methods

A model was generated based on a national data set that incorporated the statistical demonstration of procedural safety, hospital annual surgical case volume, and travel distance and time. Elective AAA repair was used to construct a hub-and-spoke model that was tested against CEA. The impact of the model was quantified in terms of mortality rates, and travel distance and time.

Results

Only 48 vascular hubs were required to provide adequate coverage in England, with the majority of patients travelling for less than 1 h to access inpatient vascular surgery. The model predicted a reduction in the number of deaths from elective surgery for AAA (P &lt; 0·001) and CEA (P = 0·016).

Conclusion

Adoption of this strategic model may lead to improved outcome after AAA and CEA. It could be used as a model for the regionalization of specialized surgery. The model does not take into account the complexity of providing a comprehensive vascular service in every locality.

The evolution of trauma services at Beaumont Hospital

OBJECTIVE

To review and examine the epidemiology, severity and management of trauma admissions at the national neurosurgical teaching hospital.

METHODS

An extensive audit of volume, type and severity of injury and the management requirements of the trauma population admitted to the hospital.

RESULTS

The vast majority of severely injured patients were referred from outside the catchment area of the hospital with only 26% being admitted directly through the Emergency Department. As a consequence, 73% of patients arrived out of normal working hours, which posed problems in providing skilled trauma specialists.

CONCLUSIONS

The management of patients with serious injury is complex. The large proportion of patients with critical injuries, some of whom were paediatric, highlighted the need for 24 h cover by senior trauma personnel and the provision of radiology and operating facilities to meet their needs. The inclusion of indicators of alterations in innate or adaptive immune responses may improve the predictive power of severity of injury scores.

Evidence‐based re‐engineering: re‐engineering the evidence

PURPOSE

Business process redesign (BPR) is used to implement organizational transformations towards more customer-focused and cost-effective care. Ideally, these innovations should be carefully described and evaluated so that "best practices" can be re-applied. To investigate this, available evidence was collected on patient care redesign projects.

DESIGN/METHODOLOGY/APPROACH

The Ebsco Business Source Premier, Embase and Medline databases were searched. Studies on innovations related to re-engineering patient care that used before-after design as minimum prerequisites were selected. General characteristics, logistic parameters and other outcome measures to determine the objectives and results and interventions used were looked at.

FINDINGS

A total of 86 studies that conformed to the criteria were found: a minority mentioned measurable parameters in their objectives. In the majority of studies, multiple interventions were combined within single studies, making it impossible to compare the effects of individual interventions. Only three randomized controlled trials were found. Furthermore, inconsistencies were noted between the study objectives and the reported results. Many more issues were reported in the results than were mentioned in the study aims. It would appear that publications were hard to find owing to a lack of specific MeSH headings. Nearly 7,500 abstracts were scanned and from these it was concluded that clear and univocal research methods, terms and reporting guidelines are advisable and must be developed in order to learn and benefit from BPR innovations in health care organizations.

ORIGINALITY/VALUE

This appears to be the first time available evidence about redesign projects in hospitals has been systematically collected and assessed.

Trauma case management: improving patient outcomes

BACKGROUND

The purpose of the study was to measure the effect of trauma case management (TCM) on patient outcomes, using practice-specific outcome variables such as in-hospital complication rates, length of stay, resource use and allied health service intervention rates.

METHODS

TCM was provided 7 days a week to all trauma patient admissions. Data from 754 patients were collected over 14 months. These data were compared with 777 matched patients from the previous 14 months.

RESULTS

TCM greatly improved time to allied health intervention (p<0.0001). Results demonstrated a decrease in the occurrence of deep vein thrombosis (p<0.038) and a trend towards decreased patient morbidity, unplanned admissions to the intensive care unit and operating suite. A reduced hospital stay LOS, particularly in the paediatric and 45-64 years age group was noted. Six thousand six hundred twenty-one fewer pathology tests were performed and the total number of bed days was 483 days less than predicted from the control group.

CONCLUSION

The introduction of TCM improved the efficiency and effectiveness of trauma patient care in our institution. This initiative demonstrates that TCM results in improvements to quality of care, trauma patient morbidity, financial performance and resource use.

Finnish Trauma Audit 2004: current state of trauma management in Finnish hospitals

There is great variation in the organisation of trauma care in European countries. The state of trauma care in Finnish hospitals has not been appropriately reviewed in the past. The aim of the present study conducted by the Finnish Trauma Association (FTA) was to assess the number of Finnish hospitals admitting severe trauma patients, and to evaluate the organisation and training of trauma care in those hospitals. In 2004, a telephone survey to all the Finnish hospitals was conducted, and information on the number of severe trauma patients treated per month, the organisation of acute trauma care, and the existence of multidisciplinary trauma care training was collected. Thirty-six Finnish hospitals admitted trauma patients. The range of estimated number of severely injured trauma patients treated in individual hospitals per month varied from 0.5 to 12, resulting in an estimated number of 1000-1300 patients with severe trauma treated in Finland every year (19-25/100.000 inhabitants). About 20% of the hospitals had a trauma team, and 25% had a systematic trauma education program. Only one hospital had established multidisciplinary and systematic trauma team training. The case load of severe trauma patients is low in most Finnish hospitals making it difficult to obtain and maintain sufficient experience. Too many hospitals admit too few patients, and only a few hospitals have been working on updating their trauma management protocols and education. There is an obvious need for leadership, discussion, legislation and initiatives by the professional organisations and the government to establish a modern trauma system in Finland.

Evaluation of Trauma Care Capabilities in Four Countries Using the WHO-IATSIC Guidelines for Essential Trauma Care

BACKGROUND

We sought to identify affordable and sustainable methods to strengthen trauma care capabilities globally, especially in developing countries, using the Guidelines for Essential Trauma Care. These guidelines were created by the World Health Organization (WHO) and the International Society of Surgery and provide recommendations on elements of trauma care that should be in place at the range of health facilities globally.

METHODS

The guidelines were used as a basis for needs assessments in 4 countries selected to represent the world's range of geographic and economic conditions: Mexico (middle income; Latin America); Vietnam (low income; east Asia); India (low income; south Asia); and Ghana (low income; Africa). One hundred sites were assessed, including rural clinics (n=51), small hospitals (n=34), and large hospitals (n=15). Site visits utilized direct inspection and interviews with administrative and clinical staff.

RESULTS

Resources were partly adequate or adequate at most large hospitals, but there were gaps that could be improved, especially in low-income settings, such as shortages of airway equipment, chest tubes, and trauma-related medications; and prolonged periods where critical equipment (e.g., X-ray, laboratory) were unavailable while awaiting repairs. Rural clinics everywhere had difficulties with basic supplies for resuscitation even though some received significant trauma volumes. In all settings, there was a dearth of administrative functions to assure quality trauma care, including trauma registries, trauma-related quality improvement programs, and regular in-service training.

CONCLUSIONS

This study identified several low-cost ways in which to strengthen trauma care globally. It also has demonstrated the usefulness of the Guidelines for Essential Trauma Care in providing an internationally applicable, standardized template by which to assess trauma care capabilities.

An association between Emergency Medicine residencies and improved trauma patient outcome

A study was done to compare trauma patient outcome at American College of Surgeons (ACS) Level l Trauma Centers with Emergency Medicine residency programs (EMRP+) to those without (EMRP-). Ten Level l Trauma Centers were reviewed from the ACS National Trauma Database (5 centers with and 5 without EM residency programs). Of 18,591 trauma patient records, 8679 were identified as EMRP-, and 9912 as EMRP+. After deleting incomplete data sets, 6621 EMRP- and 6150 EMRP+ records remained. Comparisons between patient age, gender, TRISS, complications, deaths, hospital, ICU and ventilator days, and numbers of burns, penetrating and blunt trauma were performed using t-test and chi-square analysis. Despite having a statistically significant older patient population, with more burn and penetrating trauma patients requiring longer ICU stays and longer ventilatory support (p < 0.0001), Emergency Medicine Residency program hospitals had a significantly lower complication rate (5.14% vs. 11.04%, respectively, p < 0.0001), death rate (4.704% vs. 5.479%, respectively, p = 0.0013), and shorter overall hospital stays (Mean 4.94 days, SD +/- 8.74 vs. 6.35 days, SD +/- 11.22, respectively, p < 0.0001) than EMRP- hospitals. The presence of Emergency Medicine residency programs at ACS Level I Trauma Centers is associated with improved trauma patient outcomes.

The association between trauma system and trauma center components and outcome in a mature regionalized trauma system

BACKGROUND

Regionalized trauma systems have been shown repeatedly to improve the outcome of seriously injured patients. However, we do not have data regarding which components of these systems have the most impact on outcome and to what degree. The objective of this study was to understand the association between various components that make up a trauma system and outcome.

METHODS

Surveys were administered to trauma directors at 59 hospitals in the province of Quebec, Canada. Data from the surveys were then linked with specific outcome variables obtained from a regionalized trauma database. Specific outcomes were assigned to trauma system- and in-hospital-based components after controlling for injury severity.

RESULTS

Over 4.8 years, 72,073 patients met inclusion criteria. Components found to affect survival after risk adjustment were prehospital notification (OR, 0.61; 95% CI, 0.39-0.94) and the presence of a performance improvement program in that hospital (OR, 0.44; 95% CI, 0.20-0.94). Increased patient volume was associated with a reduction in risk-adjusted mortality (OR, 0.98; 95% CI, 0.97-0.99). Tertiary trauma centers were also associated with a reduction in risk-adjusted mortality compared with both secondary and primary centers (OR, 0.68; 95% CI, 0.48-0.99).

CONCLUSIONS

Improvements in outcome in a regionalized trauma system are secondary to a combination of elements, as well as to the interplay of these elements on each other. Prehospital notification protocols and performance improvement programs appear to be most associated with decreased risk-adjusted odds of death.

Preparing teams for low-frequency emergencies in Norwegian hospitals

BACKGROUND

Medical emergencies and major trauma require optimal team function. Leadership, co-operation and communication are the most essential issues. Due to low caseloads such emergencies occur rarely in most Norwegian hospitals. Team training of personnel between real emergencies is expected to improve performance in comparable settings. Most hospitals have cardiac arrest teams, but it is known that the training of such multiprofessional teams varies widely. We wanted to know if this also was the case for trauma teams and resuscitation teams for newborns.

METHODS

A telephone survey of training practices in all the Norwegian hospitals with acute cover was conducted in 2002. Information was obtained on whether trauma teams and neonatal resuscitation teams had participated in practical multiprofessional training during the previous 6 or 12 months.

RESULTS

Information was obtained from all 50 hospitals. Of the acute care hospitals, 30% had trained their trauma teams during the previous 6 months, and an additional 18% when considering the previous year, while 38% of neonatal wards had multiprofessional training during the previous 6 months, and additionally 13% had had training during the previous year. Additionally four neonatal wards had had regular training of nurses only. More than 80% of all respondents judged regular team training to be achievable, and none considered this training impossible.

CONCLUSION

Only half the Norwegian acute care hospitals reported at least yearly training of trauma and neonatal resuscitation teams. Regular team training represents an underused potential to improve handling of low-frequency emergencies.

Trauma-care systems in Canada

Injury is a leading cause of morbidity and mortality in Canada and health-care costs associated with injury and trauma are significant. Trauma systems and standards have been defined by the Trauma Association of Canada. A National Trauma Registry has also been introduced, which has become an important resource for measuring the impact of this condition. The Registry has also been an important tool for trauma-centre quality control and assessment. The strengths of organized Canadian trauma care are described, as are current challenges.

American College of Surgeons, Committee on Trauma Verification Review: does it really make a difference?

BACKGROUND

Although not directly involved in designation per se, the American College of Surgeons (ACS) Committee on Trauma verification/consultation program in conjunction with has set the national standards for trauma care. This study analyzes the impact of a recent verification process on an academic health center.

METHODS

Performance improvement data were generated monthly from the hospital trauma registry. Forty-seven clinical indicators were reviewed. Three study periods were defined for comparative purposes: PRE (January, June, October 1997), before verification/consultation; CON (April 1999-October 1999), after reorganization; and VER (November 1999-September 2000), from consultation to verification.

RESULTS

Statistically significant (p < 0.05) quantitative and qualitative changes were observed in numbers (percent) of patients reaching clinical criteria. These included prehospital, emergency department, and hospital-based trauma competencies. Trauma patient evaluation (including radiology) and disposition out of the emergency department (< 120 minutes) improved in each study section (PRE, 21%; CON, 48%; VER, 76%). Enhanced nursing documentation correlated with improved clinical care such as early acquisition of head computed axial tomographic scans in neurologic injured patients (PRE, 66%; CON, 97%; VER, 95%). Intensive care unit length of stay (< 7 days) decreased (PRE, 87%; VER, 97.8%). Other transformations included increase in institutional morale with recognition of trauma excellence within the hospital and resurgence of the trauma research programs (60 institutional review board-approved projects).

CONCLUSION

The ACS verification/consultation program had a positive influence on this developing academic trauma program. Preparation for ACS verification/consultation resulted in significant improvements in patient care, enhancement of institutional pride, and commitment to care of the injured patient.

Initial management of the poly-trauma patient: a practical approach in an Australian major trauma service

The initial management of the poly-trauma patient is of vital importance to minimizing both patient morbidity and mortality. We present a practical approach to the early management of a severely injured patient as practiced at Liverpool Hospital in Sydney, Australia. Specific attention is paid to innovations in care and specific controversies in early management as well as local solutions to challenging problems.

Relative importance of designation and accreditation of trauma centers during evolution of a regional trauma system

BACKGROUND

Improved survival after injury has been demonstrated with trauma system implementation and designation of trauma centers. Local designating health authorities or national verification (United States) or accreditation (Canada) programs audit trauma center performance. The relative importance of designation versus accreditation with respect to improved outcomes is not clear. The purpose of this study was to measure outcomes within a single regional trauma system after designation of trauma centers and to compare outcomes in the one accredited center to the nonaccredited centers.

METHODS

Data from three trauma centers were studied. All were large, university-affiliated regional medical centers, integrated into a regional trauma system and served by a single ambulance service. The study period was 1992 to 1999, immediately after trauma center designation in 1991. The British Columbia Trauma Registry was used to identify trauma patients, mechanism of injury, length of stay, case mix, case volume, acuity, pediatric caseload, and proportion of transfers at each center. A questionnaire was circulated to each hospital to determine the level of institutional support and programmatic development for trauma. The Trauma Registry was used to calculate z scores (TRISS methodology) for each center and TRISS-adjusted mortality odds ratios between institutions. Differences in covariables were controlled for in subgroup analysis.

RESULTS

Two centers (hospitals A and C) had a high trauma caseload; one (hospital B) had a small and diminishing caseload. Only one center (hospital A) developed a trauma program consistent with Canadian accreditation criteria; z scores for center A were consistently better than at hospital B or C and survival odds ratios were significant. This finding applied to the total trauma population, blunt adult trauma patients (whether or not transfers and hip fracture patients were excluded), and in the more severely injured blunt trauma subgroups. There were no differences between hospitals for the relatively small number of patients with penetrating trauma.

CONCLUSION

Differences between hospitals were apparent from the outset of the trauma system. However, designation as a trauma center does not appear to necessarily improve survival in large regional medical centers. Development of a trauma program and commitment to meeting national guidelines through the accreditation process does appear to be associated with improved outcome after injury.

The impact on outcomes in a community hospital setting of using the AANS traumatic brain injury guidelines. Americans Associations for Neurologic Surgeons

BACKGROUND

Traumatic brain injury poses a serious public health challenge. Treatment paradigms have dramatically shifted with the introduction of the American Association of Neurologic Surgeons (AANS) Guidelines for the Management of Severe Head Injury. Implementation of the AANS guidelines positively affects patient outcomes and can be successfully introduced in a community hospital setting.

METHODS

Data were collected both retrospectively and prospectively from the records of all trauma patients between 1994 and 1999. A cohort of 93 patients was selected. Thirty-seven patients were treated before the implementation of the AANS guidelines, and these were statistically compared with 56 patients treated after the implementation of the guidelines.

RESULTS

Implementation of the recommendations in the AANS guidelines in a standardized protocol resulted in a 9.13 times higher odds ratio of a good outcome relative to the odds of a poor outcome or death compared with a group managed before the practice change. A Glasgow Coma Scale (GCS) admission score > 8 was associated with a 6.58 times higher odds ratio of a good outcome compared with a GCS admission score < or = 8. Odds ratio of a good outcome decreased by a factor of 0.92 for each year increase in age of patients starting at age 9. A dedicated neurotrauma team and comprehensive treatment algorithms are critical elements to this success. Hospital charges increased by more than $97,000 per patient, but are justifiable in the face of significantly improved outcomes.

CONCLUSION

Implementation of a traumatic brain injury protocol in a community hospital setting is practical and efficacious. Appropriate invasive monitoring of systemic and cerebral parameters guides care decisions. The protocol results in an increase in resource usage, but it also results in statistically improved outcomes justifying the increase in expenditures.

Trauma education

OBJECTIVE

Trauma is a diverse disease in which time critical decisions and skills affect patient outcome. This review article examines the methods and assessment of education for the management of the trauma patient.

METHOD

Literature review.

RESULTS

Education is a planned experience that leads to a change in behaviour. Adult education methods can be used to improve the knowledge, skills, attitudes and relationships of health care workers. Adult learners need careful consideration of lecture style, small group work, role play and skills stations in order to achieve these aims. These techniques are typically used in short intensive courses such as Advanced Trauma Life Support (ATLS) aimed at the initial care of the trauma patient. There is a relative lack of education directed at definitive care. It is important to assess the impact of trauma education in terms of clinical process, retention of skills/knowledge and the outcome of patients. A generic approach (the ABC approach) is applicable to the care of all critically ill or injured patients. This approach should be taught at junior level.

CONCLUSION

The care of trauma patients can be improved by educating health care workers using adult educational strategies.